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Line of Duty Injury

Line of Duty Death

Non-Line of Duty Death

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"The future of my career as well as the quality of my mobility was uncertain…I want to thank everyone at the 100 Club for lessening the burdensome load." - US Border Patrol Senior Agent Phillip Bidwell

Line of Duty Death / Non-Line of Duty Death
Request Form for Potential Benefits

To request benefits , fill out the following form as complete as possible.

Date of Death:
Line of Duty:	Yes No
Years of Service:
Personal Information of Deceased Party
First Name:
Last Name:
Date of Birth:
Title/Position:
Spouse (If applicable)
First Name:
Last Name:
Date of Birth:
Contact Information for Injured Party
Address:
Address 2:
City:
State:
Zip:
Home Phone:
Mobile Phone:
Other Phone:
Email Address:
Make Benefit Check To:
Dependents (Other than spouse)
Dependent 1 Name:
Dependent 1 Date of Birth:
Dependent 2 Name:
Dependent 2 Date of Birth:
Dependent 3 Name:
Dependent 3 Date of Birth:
Dependent 4 Name:
Dependent 4 Date of Birth:
Information Provided By:
First Name:
Last Name:
Title/Position:
Office Phone:
Mobile Phone:
Fax:
Email:
Department/Agency:
Address:
City:
State:
Zip:
Events of Death: (Provide who, what, when, where, how, reports, articles, if available.)


When you click the button below your benefits request will be emailed to the 100 Club Office.

100 Club Sponsors

Benefits Forms

Testimonials

Line of Duty Death / Non-Line of Duty Death Request Form for Potential Benefits

Line of Duty Death / Non-Line of Duty Death
Request Form for Potential Benefits